ALL Practice Questions

The nurse finds that a patient who has urinary incontinence scores 11 on the Braden Scale. Which nursing action is most appropriate to prevent this patient from developing pressure injuries. -Managing shear -Managing moisture -Proving nutrition intervention -Providing foam wedges for positioning

-Managing moisture **A patient who has urinary incontinence has very sensitive skin is at increased risk of destruction.

The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction? 1. "The enema will be given while I am sitting on the toilet." 2. "I would try and hold the fluid as long as possible after it is run in." 3. "I know that there will be some cramping after the enema solution is run in." 4. "I would tell the nurse if cramping occurs when the fluid is running in."

1. "The enema will be given while I am sitting on the toilet." **The enema is never administered while on a toilet due to safety. The enema is administered while the patient is left side lying position with the right knee flexed. This allows the enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum. It is important for the patient to retain the fluid for as long as possible to promote peristalsis and defecation. If the client complains of fullness or pain, the flow is stopped for 30 seconds and is restarted at a slower rate. The higher the solution container is held above the rectum, the faster the slow and the greater the force in the rectum; this could increase cramping.

The nurse is preparing to irrigate a sigmoid colostomy. The nurse would plan for which intervention? 1. Instilling 500 to 1000 mL of lukewarm tap water through the stoma 2. Advising the client to hold breath if cramping occurs during installation. 3. Hanging the irrigation solution so that the bottom of the bag is 18 inches above the client's torso 4. Inserting the irrigation tube with force & a twisting motion into the stoma & unclamping the tubing to allow the solution to flow into the stoma

1. Instilling 500 to 1000 mL of lukewarm tap water through the stoma **Clients with sigmoid colostomies may require irrigation of the stoma to promote regular colon emptying. Irrigation is performed by instilling 500 to 1000 mL of lukewarm tap water through the stoma and then allowing the irrigation solution and stool to drain into a collection bag. The nurse hangs the irrigation solution so that the bottom of the bag is level with the clients shoulder. The nurse inserts the irrigation tube without force into the stoma and unclamps the tubing to allow the solution to flow into the stoma. The nurse would unclamp the tubing if cramping occurs and then resume the installation as tolerated.

A client with a colostomy has a prescription for irrigation of the colostomy. Which solution would the nurse use for the irrigation? 1. Tap water 2. Sterile water 3. Sterile distilled water 4. Sterile lactated Ringer's

1. Tap water **Warm tap water or saline solution is used to irrigate a colostomy. If the tap water is not suitable for drinking, bottled water needs to be used.

The client has a prescription for the administration of an enema. After preparing the equipment and solution, the nurse would assist the client into which position? 1. Right-sided lateral position 2. Modified left lateral position 3. Left side, with the head of the bed elevated 45 degrees 4. Right side, with the head of the bed elevated 45 degrees

2. Modified left lateral position **For the administration of an enema, the client is placed in a modified left lateral position so that the enema solution can flow by gravity in the natural direction of the colon. The client is lying on his or her side, with the body turned approximately 45 degrees. The lower leg is extended, with the upper leg flexed at the hip and knee to a 45-90 degree angle.

The nurse orientee is preparing to insert a nasogastric tube, and the nurse educator is observing the procedure. Which item, if obtained by the nurse orientee, would indicate a need for further teaching regarding this procedure? 1. Half-inch tape 2. Oil-soluble lubricant 3. A 50-mL catheter tip syringe 4. A glass of tap water with a straw

2. Oil-soluble lubricant **Water-soluble lubricant is used to lubricate 3 to 4 inches of the tube at the insertion end. An oil lubricant is not used because if the tube accidentally goes into the bronchus, pneumonia can develop. **Half-inch tape is used to secure the tube after correct placement is verified. A 50-mL catheter tip syringe is used to aspirate gastric contents to help verify placement. Only a chest x-ray can confirm placement. The client will be asked to take a sip of water through a straw to help with the passage of the tube.

A primary health care provider has ordered digital removal of stool for a constipated client. How would the nurse position the client for this procedure? 1. Prone position 2. Lithotomy position 3. Left lateral side-lying position 4. Right lateral side-lying position

3. Left lateral side-lying position **For digital removal of stool, the client would be placed in the left lateral side lying position, as this position follows the anatomical curvature of the colon.

The registered nurse is preparing to insert a nasogastric tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse would take which action? 1. Mark the tube at 10 inches. 2. Mark the tube at 32 inches. 3. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process. 4. Place the tube at the tip of the nose and extend the tube to the earlobe and down to the top of the sternum.

3. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process. **Measuring the length of a nasogastric tube needed is done by placing the tube at the tip of the client's nose and extending the tube to the earlobe and then down to the xiphoid process. The average length for an adult is about 22 to 26 inches (56 to 66 cm).

To prevent postoperative atelectasis in a client recovering from an open cholecystectomy, what would the nurse do first? 1. Request a cardiopulmonary consult. 2. Teach the client to splint the incision. 3. Teach the proper technique for huff coughing. 4. Ensure that the client is experiencing adequate pain control.

4. Ensure that the client is experiencing adequate pain control. **Coughing is one of the protective reflexes. It moves mucus that is in the airways upward toward the mouth and nose. It is needed in the postoperative patient to mobilize secretions and expel them from the airways to prevent atelectasis. The patient with an abdominal incision is hesitant to cough unless pain control is adequate. The incision is an open cholecystectomy is just under the diaphragm in the RUQ of the abdomen, making coughing and deep breathing painful. The nurse would first ensure that pain control is adequate so that pulmonary hygiene measures are maximally effective. Splinting the incision is an effective postoperative strategy for assisting with effective coughing and deep breathing, but it would follow pain control. Huff coughing, although it can be used in the postoperative client, is an effective coughing strategy that is most often recommended for clients with chronic obstructive airway disorders.

The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How would the nurse best determine the presence of erythema? 1. Assess for drainage from the wound. 2. Assess for redness around the wound edges. 3. Palpate for swelling around the wound edges. 4. Palpate for increased skin temperature around the wound edges.

4. Palpate for increased skin temperature around the wound edges. **Erythema is a form of macula characterized by diffuse redness of the skin. In a dark-skinned client, erythema is best determined by palpating for increased skin temperature. **Redness around the wound edges may be difficult to note in the dark-skinned client. Swelling and drainage from the wound are not specific indicators of erythema.

The nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate action? 1. Insert the tube quickly. 2. Notify the primary health care provider immediately. 3. Remove the tube and reinsert it when the respiratory distress subsides. 4. Pull back on the tube and wait until the respiratory distress subsides.

4. Pull back on the tube and wait until the respiratory distress subsides. **During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. **It is not necessary to notify the primary health care provider immediately or remove the tube completely. Quickly inserting the tube is not an appropriate action because, in this situation, it is likely that the tube has entered the bronchus.

The nurse is preparing to administer a soapsuds enema to a preoperative client. In which position would the nurse place the client to administer the enema? Click on the image to indicate your answer.

**To administer an enema, the nurse assists the client into the modified left lateral position with the right knee flexed. This position allows the enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum, thereby improving the retention of the solution.

The nurse administers an analgesic medication to a patient with a stage 4 pressure ulcer who needs to have a dressing change. When does the nurse perform the dressing change in relation to administering the analgesic? -Before the administration -90 minutes after administration -Immediately after administration -30-60 minutes after administration

-30-60 minutes after administration **Dressing changes should always be done after the analgesic is given.

Which psychologic symptom is associated with a sleep deprived patient? Select all that apply. -Ptosis -Agitation -Hyperactivity -Disorientation -Cardiac arrhythmias

-Agitation -Hyperactivity -Disorientation **Ptosis and cardiac arrhythmias are physiologic symptoms.

Which physiologic symptom would the nurse expect to find in a patient with sleep deprivation? Select all that apply. -Quick response time -Blurred vision -Cardiac arrhythmias -Diminished reflexes -Decreased hearing

-Blurred vision -Cardiac arrhythmias -Diminished reflexes -Decreased hearing **Sleep deprivation may slow down all the body systems.

The laboratory reports of an immobilized patient indicate the presence of thrombus. Which changes in the body are responsible for this condition in this patient? -Metabolic changes -Respiratory changes -Cardiovascular changes -Musculoskeletal changes

-Cardiovascular changes **Cardiovascular changes in the body lead to orthostatic hypotension, increased cardiac workload, and thrombus formation. **The metabolic changes alter the endocrine metabolism and calcium resorption. **The respiratory changes alter pulmonary complications such as atelectasis and hypostatic pneumonia. **The musculoskeletal changes are temporary impairment and permanent disability.

The nurse is caring for a patient with paralysis. The nurse understands that footdrop is a common but preventable complication in these patients. Which statement is true about foot drop? Select all that apply. -Footdrop is a type of debilitating contracture. -The foot is permanently fixed in dorsiflexion position. -The patient is unable to lift the toes off the ground. -Patients with left or right side paralysis are at increased risk of developing footdrop. -Footdrop can be treated with regu

-Footdrop is a type of debilitating contracture. -The patient is unable to lift the toes off the ground. -Patients with left or right side paralysis are at increased risk of developing footdrop. **Footdrop is the most common type of debilitating contracture. The patient is unable to life the toes from the ground, making it difficult to ambulate. The foot is permanently fixed in plantar flexion. Once it occurs, it can not be treated. It is prevented through regular physiotherapy.

Which sleep deprivation symptom is psychologic? -Slowed reflexes -Fine motor clumsiness -Increased sensitivity to pain -Decreased auditory alertness

-Increased sensitivity to pain **The other options are physiologic

The nurse is preparing to discontinue a client's nasogastric tube. The pt is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse would make which statement? 1. "Take a deep breath when I tell you, and hold it while I remove the tube." 2."Take a deep breath & bear down when I remove the tube." 3."Take a deep breath & slowly exhale when I remove the tube." 4. "Take a deep breath & breathe normally when I remove the tube."

1. "Take a deep breath when I tell you, and hold it while I remove the tube." **The patient would take a deep breath, because the patient's airway will be temporarily obstructed during tube removal. The patient is then told to hold the breath and the tube is withdrawn slowly and evenly over the course of 3-6 seconds (coil the tube around the hand while removing it) while the breath is held. **Bearing down could inhibit the removal of the tube. Exhaling is not possible during removal because the airway is temporarily obstructed during removal. Breathing normally could result in aspiration of gastric secretions during inhalation.

The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis? Select all that apply. 1. Sclerae 2. Tongue 3. Nail beds 4. Elbows and heels 5. Mucous membranes

2. Tongue 3. Nail beds 5. Mucous membranes **Skin color may be more difficult to assess in the client with dark skin. The best areas to use to detect pallor and cyanosis include the tongue, nail beds, and mucous membranes.

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse would place the client in which position? 1. Modified left lateral position 2. Modified right lateral position 3. On the left side of the body, with the head of the bed elevated 45 degrees 4. On the right side of the body, with the head of the bed elevated 45 degrees

1. Modified left lateral position **For administering an enema, the client is placed in a modified left lateral position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated when administering an enema.

A client's nasogastric feeding tube has become clogged. The nurse would take which action first? 1. Replace the tube. 2. Aspirate the tube. 3. Flush with carbonated liquids. 4. Flush the tube with warm water.

2. Aspirate the tube. **The first step in attempting to unclog a feeding tube is to gently aspirate the tube. **If this is unsuccessful, flushing the tube with warm water can be tried. Carbonated liquids sometimes are used for flushing a clogged tube (depending on agency policy and procedures), but the tube must be rinsed thoroughly afterward to avoid stickiness. Replacement of the tube is the last step if other actions are unsuccessful. Also, the primary health care provider may prescribe another method of alleviating the obstruction.

The nurse is preparing to provide wound care to a client with a stage 1 pressure injury. Which dressing would the nurse expect to be prescribed in the treatment of this wound? 1. Hydrogel dressing 2. Transparent dressing 3. Antimicrobial dressing 4. Calcium alginate dressing

2. Transparent dressing **A stage 1 pressure injury is characterized by intact skin with nonblanchable erythema. Dressings used to manage a stage1 pressure injury include transparent dressings, hydrocolloid dressings, or no dressing and leaving the wound open to air. The wound should resolve without epidermal loss over a period of 7 to 14 days. **Calcium alginate is absorbent and is used in stage 4 wounds or those with deeper tissue injury. Antimicrobial dressings are used for pressure injuries that are infected.

The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate? 1. Notify the surgeon. 2. Clamp the surgical drain. 3. Change the dressing as prescribed. 4. Remove and replace the perineal packing.

3. Change the dressing as prescribed. **Immediately after surgery, profuse serosanguineous drainage from the perineal wound is expected. Therefore, the nurse needs to change the dressing as prescribed. **A surgical drain would not be clamped because this action will cause the accumulation of drainage within the tissue. The nurse does not need to notify the surgeon at this time because this is expected. Drains and packing are removed gradually over a period of 5 to 7 days as prescribed. The nurse would not remove the perineal packing.

The nurse is preparing to insert a nasogastric tube into a client. The nurse would place the client in which position for insertion? 1. Right side 2. Low-Fowler's 3. High-Fowler's 4. Supine with the head flat

3. High-Fowler's **During insertion of a nasogastric tube, the client is placed in a sitting or high-Fowler's position to facilitate insertion of the tube and reduce the risk of pulmonary aspiration if the client would vomit. **The right side, low-Fowler's, and supine positions place the client at risk for aspiration; in addition, these positions do not facilitate insertion of the tube.

The nurse is preparing to insert a nasogastric tube (NG) into a client. What nursing measure will best facilitate insertion of the tube? 1. Placing the NG tube in warm water 2. Hyperextending the head to insert the tube 3. Removing the tube if any resistance to insertion is met 4. Asking the client to swallow as the tube is being advanced

4. Asking the client to swallow as the tube is being advanced **To facilitate insertion best, when the tube reaches the pharynx, the client is encouraged to lower the head slightly, swallow and, if allowed, take sips of water. **The NG tube would be iced to stiffen it, which eases insertion. If resistance is met, the tube is withdrawn and repassed. The correct option is the only one that would facilitate insertion.

Before enema administration, the nurse positions the client in a left lateral position. What is the rationale for using this position? 1. It is more comfortable. 2. It facilitates the passage of stool. 3. It prevents a vasovagal response from occurring. 4. It facilitates instillation of the enema solution into the colon.

4. It facilitates instillation of the enema solution into the colon. **The sigmoid and descending colons are located on the left side. Therefore, the left lateral position uses gravity to facilitate the flow of the solution into the sigmoid and descending colons. Acute flexion of the right leg allows for adequate exposure of the anus.

A client states to the home health nurse that they have not had a bowel movement since coming home from the hospital after surgery 4 days ago. The nurse instructs the client to follow which diet at this time? 1. High-fiber diet 2. Full liquid diet 3. Low-fiber diet 4. Low-sodium diet

1. High-fiber diet **Constipation is the probable cause of the clients lack of bowel movements. Constipation is the difficult or infrequent passage of stools, which are hard and dry. Constipation has numerous causative factors, including psychogenic, lack of physical activity, inadequate intake of food and fiber, and medication influences. A high fiber diet is often indicated for constipation because it will promote bulk and encourse intestinal peristalsis.